ENSURING THE CONTINUITY OF MEDICAL CARE AT THE STAGE OF PATIENTS REHABILITATION
ZAPEWNIENIE CIĄGŁOŚCI OPIEKI MEDYCZNEJ U CHORYCH PODDAWANYCH REHABILITACJI
Оleksandr Sarkanich, Оlena Shevtsova, Ozar Mintser
Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine
The problems of ensuring continuity of medical care are considered. Information and cybernetic issues of continuity, in particular information standards, resource management systems of a medical institution, are analyzed. It emphasizes the need to develop standards for the continuity of care. It is concluded that long-term continuity of medical measures in rehabilitation is one of the main components of the effectiveness of medical care. Further qualitative research is needed, including some types of rehabilitation services (e. g. specialized medical care). At the same time the most important factors for ensuring continuity at the current stage of medicine development are the use of ontologies, representing the most general conceptual concepts of the modeled field of medicine, completely abstracted from specific models of knowledge representation and practical implementation. It is also shown that the specification of the patient management model in the rehabilitation period of treatment is provided by a wide application of telemedicine consultations. The index of continuity of medical aid is also proposed. It represents a simple additive function that reflects the change in the probability of an unfavorable outcome.
Key words: continuity of medical care, accessibility of medical care, quality of medical care, information standards of continuity of medical care, quantitative characteristics in the evaluation of continuity of care, knowledge ontology, telemedicine
Wiad Lek 2019, 72, 2, 275-278
According to the today’s point of view on the providing of medical care, physical rehabilitation plays a significant role. Its particular importance lies in the maintenance and restoration of body function, the prevention of possible recurrences of the pathological process and the avoidance of complications.
At the same time, due to a certain fragmentation of the treatment (especially in case of sudden exacerbations of the disease), rehabilitation is usually carried out individually according to individual clinical disciplines without substantial or even formal coordination. It is important to underline that most international studies emphasize a rather high level of problems associated with the coordination of medical care in real conditions when many specialists involved in the treatment of one patient. The growing interest among rehabilitation specialists in the development of policies conducive to continuity and succession of rehabilitation assistance is consistent with international efforts to maintain and strengthen continuity in the health care system in general. However, despite the growing interest, research on the continuity of rehabilitation assistance is extremely insufficient [13, 14].
The aim of this study is to formalize the definitions, procedures and conclusions in the problem of medical care continuity.
Review and discussion
Let’s discuss the conceptual basis of the medical care continuity first. Usually, under these terms coordination of activities in the process of providing the patient with medical care at different times by various specialists and medical institutions is understood. A simplified approach largely links the continuity in the providing of medical care with standard requirements for medical documentation, technical equipment, process and personnel. It is assumed that such coordination of the health workers activities guarantees the stability of the treatment process and its result [19, 5].
However, in reality, the continuity of medical activity, as a rule, is not ensured by this. Note that the concept of “coordination” is poorly defined. It does not contain quantitative parameters and is understood by different authors and the majority of physicians in different ways.
In addition, continuity is strongly influenced by accompanied factors, such as the medical care availability, medical errors in diagnostic and therapeutic procedures, etc.
Under the continuity we will understand such a sequence of actions of doctors in which the probability of an adverse outcome of the pathological process or possible complications does not increase at least. We have previously discussed a similar approach in clinical medicine [2, 6].
It is quite obvious that in order to achieve continuity of medical care it is necessary to fulfill many other conditions.
The first factor that affects the continuity is the availability of medical care. It is the most important condition for the medical care providing to the population in all countries of the world, reflecting both the economic capabilities of the state as a whole and the capabilities of a particular person. Unfortunately, universal and equal access to all types of medical services is not ensured anywhere. This kind of approach to the use of limited resources is called rationing and is practiced to varying degrees in all countries of the world.
Defects in the quality of medical care have a strong effect on the medical care continuity. According to the international statistics, the most significant causes of defects in the work of doctors are insufficient qualifications of medical workers, inadequate examination of patients, inattention to the patient, limitations in the medical process organization, underestimation of the patient’s condition severity [4, 5]. Note that, according to some data, defects in the medical care organization make up at least 15% of all defects in medical care .
Another factor in ensuring continuity is the medical care continuity. The most important role in its control play the information mechanisms. Therefore, to ensure continuity in international practice, a corresponding standard was created, which was called the CCR (Continuity of Care Record) . In general, the CCR has data that includes two large clusters: a patient’s health summary (e.g., diagnosis, medications, allergies) and basic insurance information. In addition, identification data and the target of the CCR are included. More detailed information about the standard is as follows. The standard has six sections and the following obligatory elements. These are 6 sections: heading; patient’s identification (demographic and administrative data); patient’s financial and insurance information; the patient’s health condition (providing as a snapshot that contains the relevant clinical data); care documentation; service plan recommendations. At the same time, this standard may present some difficulties in the implementation of interdisciplinary and transdisciplinary approaches [8,10,16].
CCR can be obtained on paper or electronically. XML coding used in electronic transmission provides some flexibility by allowing users to prepare, transmit and view CCR in several ways, for example in a browser, as a Health Level 7 (HL7) element; message as a PDF file, either as an HTML file, or as a document for text processing. Naturally, data protection is provided.
It is worth to note that the formalization of the patient’s condition data and recommendations for its further management is clearly insufficient. As a result, it was noted that the transfer of information between doctors who provide continuous and successive medical care, has a number of problems. It is revealed that therapists and resuscitators in the majority note the insufficiency or even absence of patient’s data regarding previous health problems [7, 18].
For example, research in the field of primary health care refers to “accumulated knowledge” and “flexibility” as corresponding factors of both information continuity and continuity of management, but it is impossible to recreate a complete clinical picture. The concept of “flexibility” of the data presented is particularly confusing. It is worth to emphasize the absence of the concept of clinical information “completeness”.
It can be argued that the existing (or planned) informatization of health care system will let to provide complete information for the actual implementation of the medical care continuity in a real life. Never the less, this is true only to a certain extent. As part of the “E-Health” strategy, it is really possible to obtain a lot of information regarding the previous periods of the diagnostic and therapeutic process in this patient. However, it is extremely difficult to ensure individualization of actions (as a rule, non-directional reaction of the patient’s body), to guarantee a personalized sequence of procedures, especially during the rehabilitation period when exposed to a new set of factors.
We have proposed to use ontologies of knowledge in ensuring the continuity of medical care. As is known, ontologies are a way of knowledge representation. The most common model for the representation of ontologies and complexly structured data are semantic networks [1, 11, 12]. As a rule, the ontology of knowledge allows you to collect and systematize data about patients, make recommendations for additional examinations, draw conclusions about the possible causes of the disease, make recommendations about the methods and means of treating, monitor the patient’s state and evaluate the efficacy of received therapy. It is important that by creating an “individual” ontology, it is possible to provide a rehabilitation specialist with reference information about the features of the pathological process, about food products and drugs used in its treatment. Moreover, on the basis of data about a particular person (anthropometric data, a list of diseases and problems related to his health and well-being, his goals), it is possible to rationale the most appropriate types of physical activity, diet, restorative or preventive procedures. In addition, the giving of directional reference information on rehabilitation complexes, their indications and contraindications is provided.
A number of studies emphasize the idea that successful rehabilitation is associated not only with such factors as trust and comfort, but also with the need to establish communication with attending physician directly during the rehabilitation period. The presence of established relationships between the attending physician and the patient increased the feeling of comfort among the participants and ensured an effective connection between past and current interventions.
Regarding this, we consider it extremely important to achieve the use of telemedicine consultations in the process of rehabilitation of patients. The innovative goal of this process is the correction of information modeling processes of the pathological process based on ontological models. The technological basis for telemedicine counseling can be the Internet. We emphasize that the favorable conditions for communication between the attending physician and the rehabilitation specialist are ensured by the fact that the connection does not require a long time, and the intellectual basis of the interaction is the standard of medical knowledge HL7 .
Let us also dwell on the quantitative characteristics of the continuity of medical care. Continuity is one of the main factors determining the administrative, demographic and clinical aspects of health care.
Regarding this, numerous indices reflecting this factor have been proposed [16, 17]. Among them, we call only the traditional patient care (TPC) (the original equivalent of the usual provider of care (UPC)), representing the ratio of the frequency of visits by the patient to the attending (family) doctor to the total number of visits. According to the literature, the TPC median is 56 (SD = 9.5, range 43–75).
An interesting is the index that determines the ratio of prescriptions of the attending physician and other medical specialists – PPM (the original equivalent is continuity for physician (PHY)). The PPM median is 55 (SD = 8.6, range 37–63).
The index of continuity of care by narrow specialists (CCNS) (the original equivalent is the continuity of care index (COCI)) is also proposed. Of course, it is lower than the TPC. Moreover, the results fall with an increase in the number of narrow specialists and, as a rule, is below other indicators of continuity. The median according to the literature is 30 (SD = 17, range 11–56).
Modified modified continuity index (MMCI)) assesses the ratio of the total number of doctors visited by the patient and the total number of visits. Of course, its value is slightly higher than the TPC. According to the literature, the MMCI median is 59 (SD = 12.9, range 43–76). It is worth to emphasize that all the listed indices do not have a direct relationship to either continuity or succession. Regarding this, we have proposed the index of medical care continuity. It is a simple additive function, reflecting a change in the likelihood of an adverse outcome.
A preliminary study of the effectiveness of this approach was performed. The value of probability was made on the basis of Wald sequential statistical analysis.
It turned out that in most cases the index retains at least a small but negative value (the median is –15, SD = 8.7, the range is (–10) – (- 21), which indicates that the problems of continuity of medical care are not leading for the doctors.
1. The long-term continuity of treatment measures in rehabilitation is one of the main components of the of medical care efficacy. Further qualitative research is needed, including some types of rehabilitation services (for example, specialized medical care).
2. The most important factor in ensuring continuity at the present stage of medicine development is the use of ontologies, that represents the most common conceptual concepts of the modeled field of medicine, completely abstracted from specific models of knowledge representation and practical implementation.
3. Specification of the patient management model in the rehabilitation period of treatment is provided by the wide use of telemedicine consultations.
4. The index of continuity of medical care is proposed. It is a simple additive function, reflecting a change in the likelihood of an adverse outcome.
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According to the order of the Authorship.
Conflict of interest:
The Authors declare no conflict of interest.
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of Postgraduate Education
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